Monday, July 20, 2015

Jim almost convinced me. The burning in his chest, after all, could have just been gastroesophageal reflux. He assured me that the sensation was nothing new; that he got it from time to time after a large meal and took Tums. I couldn't, however, ignore that it seemed to worsen with activity. The pain was bothersome enough to drag him into my office, without taking the time to make an appointment.

Jim and I argued over the EKG. He wanted to take his prescription and go home. No hospitalization, no blood tests, no diagnostic studies. I grabbed his shoulder, and did my best to convince him to reconsider. He slowly turned back toward the exam room. A few minutes later, I gulped as I looked down at the electrocardiogram. He was having a heart attack. Right there in my office. We called an ambulance and rushed him to the ER.

Jim's story is nothing new. I can recall countless episodes of personal beliefs contradicting my strongly held suspicions as a clinician. I have begged, pleaded, and occasionally dragged unwilling patients back to the office or into the emergency room.

And occasionally I have saved their lives, or interrupted a malignant disease process before the effects could become irreversible.

Sometimes we are not so lucky. Many clinicians can recall a case in which they had been lulled into a false sense of security by a patient's own certainty. There is nothing worse than a call from an emergency room, specialist, or coroner notifying you of a deadly misjudgement.

Conversely, everyday we face patients who are utterly convinced that they know what is wrong. These beliefs, occasionally correct, but often heretical can be terribly difficult to dispel and lead to over-testing and over-diagnosis.

It's quite a slippery slope.

So when I read in the newspaper about the latest story of the mishap patient who was certain of the correct diagnosis, yet their pleas fell deaf on their doctor's ears, I kind of get it.

The layman's diagnosis is often wrong, but sporadically on target. It takes great courage and concentration to accurately weigh the data, the patient's beliefs, and empiric science. We actually get it right far more often than not.

Sunday, July 12, 2015

It was only afterwords that I wondered if I had been condescending. The words had come out so naturally. We were sitting across from each other in the nursing home. It didn't take a doctor to recognize that his leg was visibly less swollen. I had seen him walking down the hallway with the physical therapist. His face a mix of pain, concentration and triumph.

Each day had brought improvements. The range of motion was returning. His strength was growing. His body balanced now with only the most minimal of assistive devices. What had once been disability had transformed to normal physiologic functioning.

In medicine we often talk in the most passive of manners. We say that the knee is improving, or the wound is closing. We talk as if healing is a mere act of God. A blessing that is bestowed on the weary from time to time in a somewhat whimsical manner.

And I am not a denier that randomness pervades our experience in hospitals and medical clinics. But I have been trying to be more cognizant of the role that human will plays in the rehabilitation of both body and soul. The force and strength, the sweat and tears, the physical act of becoming healthy.

So I said what was on my mind.

You know, I'm really proud of you!

Funny words coming from a middle aged doctor to his geriatric patient. But his face lit up, and I could see that he was thankful for the recognition of the difficult road he had travelled and barriers that still lay ahead. It wasn't condescending. It was a truthful moment that transcended the artificial barriers between doctor and patient. I was just an innocent bystander acknowledging the remarkable personal will it took to get better.

I feel both awe and pride, frequently, at the strength and endurance of those patients that fill my moment to moment existence.

Friday, July 3, 2015

Like two ships passing in the night, we sidled up to each other at the nursing station on the hospital telemetry ward. I had already been home, ate with the kids, and returned, while he hadn't left floors all day. We typed away at our computer stations, and chatted from time to time.

After we exchanged common pleasantries, we jumped into local politics. We were hungry for news. Battle worn and weary, we were searching for signs the tide was starting to turn. The gossip was mostly pessimistic, but I saw a glimmer in his eye as he abandoned his screen and turned to face me.

I bet you haven't heard about...(fill in the name of your favorite academic medical center).

He was exited now. The words came from his mouth faster than the keystrokes that disdainfully filled the electronic medical record that had become his slave master. An academic center had taken over a hospital, and felt that it had every right to bully the large allied medical group. The physicians, tired of being pushed around, silently vowed to steer their admissions to a local competitor. Months later, the academic center was on it's knees with empty beds and an angry community to boot.

We both basked in the glow momentarily before returning to our respective tasks. Although we wanted to go back home to our families, there remained a need to share a fleeting moment with someone who could relate. Someone who could understand.

And I imagine that conversations like these are taking place across the country where physicians congregate: hospitals, clinics, and doctor's lounges.

I find it rather disconcerting that a decade ago, colleagues used to revel in a recent save, discuss a difficult prognostic dilemma, or brag about a diagnosis of a rare ailment when happenstance caused their paths to cross in the middle of the night.

But now, now all we talk about is sticking it to the man.

And I wonder how those, at the moment, dying to find appropriate medical care,